Impact of Surgeons’ Experience on Implant Placement Accuracy Using a Dynamic Navigation System: A Cadaver Pilot Study
, Camillo Vocaturo 1,*,†, Armando Crupi 1, Beatrice Longhi 1, Alessandro Campagna 1, Antonino Fiorino 2, Umberto Gibello 1,3,‡ and Andrea Roccuzzo 4,5,6,‡
Round 1
Reviewer 1 Report
Comments and Suggestions for Authors
Dear Authors,
This study aims to contribute to dental research by comparing practitioners' experiences with implant placement accuracy using a dynamic navigation system.
This manuscript's topic is not only interesting but also of great value, as implant implant placement might present some clinical challenges. Your work in this area is highly appreciated. However, some concerns related to the report need to be addressed.
Introduction
· The introduction provides a solid and well-supported context for the manuscript's subject, but I suggest that this paragraph be better organized and that redundant information be eliminated (e.g., lines 70-79 present information that is repeated in lines 81-88).
· The abbreviation for computer-assisted surgical CAS is used throughout the document, but lines 89-90 use CAIS, so I suggest consistency in this regard.
Materials and Methods
This section is well presented, and the methodology is well explained, but some issues can be raised.
· Figure 1- I suggest replacing it with a more relevant one since it cannot be deduced precisely from what it is intended to represent. Similarly, the figures are meant to be introduced in the text after their citation, under the journal's editorial requirements. Also, do not abbreviate Table and Figure to Tab. or Fig.
· Figure 3 is not cited in the text.
· “A total of twenty-six implants (15 Nobel Replace Conical Connection 4.3x13mm in mandible & 11 Nobel Active Ti Ultra 4.3x13mm in maxilla, Nobel Biocare) were placed and analyzed in three fresh defrozen cephali.” this phrase was used multiple times the lines 111-113, 156 – 158, 279 – 281. I suggest that only the one from lines 156 -158 be maintained.
· Was bone density taken into account?
· Statistical Analyses
o How was calculated the sample size?
o Although the use of t-test and ANOVA is mentioned, details about the selection of these methods or the justification for their use are limited. There is no discussion of possible adjustments for a small sample size.
Discussion
This section is well structured, reinforcing the study's main findings and explaining their clinical relevance.
Conclusions
· I suggest that the first conclusion be modified in accordance with the study's limitations because it is an excessive generalization based on a very small sample and without evaluating essential clinical factors (e.g., bone density variation, complexity of real cases).
· The last paragraph is a repetition of information presented in the discussions; I suggest removing it.
Author Response
Comment 1: The introduction provides a solid and well-supported context for the manuscript's subject, but I suggest that this paragraph be better organized and that redundant information be eliminated (e.g., lines 70-79 present information that is repeated in lines 81-88).
Response: We thank the reviewer for the relevant comment. We have revised this section as suggested.
Comment 2: The abbreviation for computer-assisted surgical CAS is used throughout the document, but lines 89-90 use CAIS, so I suggest consistency in this regard.
Response: We thank the reviewer for the relevant comment. We have revised this section as suggested.
Comment 3: Figure 1- I suggest replacing it with a more relevant one since it cannot be deduced precisely from what it is intended to represent. Similarly, the figures are meant to be introduced in the text after their citation, under the journal's editorial requirements. Also, do not abbreviate Table and Figure to Tab. or Fig.
Response: We thank the reviewer for the relevant comment. We have amended all these aspects section as suggested.
Comment 4: Figure 3 is not cited in the text.
Response: We thank the reviewer for the relevant comment. We have added the required details related to Figure 3 as suggested.
Comment 5: A total of twenty-six implants (15 Nobel Replace Conical Connection 4.3x13mm in mandible & 11 Nobel Active Ti Ultra 4.3x13mm in maxilla, Nobel Biocare) were placed and analyzed in three fresh defrozen cephali.” this phrase was used multiple times the lines 111-113, 156 – 158, 279 – 281. I suggest that only the one from lines 156 -158 be maintained.
Response: We thank the reviewer for the relevant comment. We have amended the text as suggested.
Comment 6: Was bone density taken into account?
Response: We thank the reviewer for the relevant comment. We have described this parameter as desctibed by Lekholm and Zarb. These information have been added within the text as suggested.
Comment 7: How was calculated the sample size?
Response: We thank the reviewer for the relevant comment. The present study is the first study applying this methodology in a cadaver model. Therefore, the authors did not have any previous reference to perform a proper sample size calculation. Being aware of this limitation, we have listed it as such within the discussion section.
Comment 8: Although the use of t-test and ANOVA is mentioned, details about the selection of these methods or the justification for their use are limited. There is no discussion of possible adjustments for a small sample size.
Response: We thank the reviewer for the relevant comment. We have double checked with a biostatistician and consequently re-run the analysis. The whole paragraph has been adapted accordingly.
Comment 9: I suggest that the first conclusion be modified in accordance with the study's limitations because it is an excessive generalization based on a very small sample and without evaluating essential clinical factors (e.g., bone density variation, complexity of real cases).
Response: We thank the reviewer for the relevant comment. We have expanded the checked with a biostatistician and consequently re-run the analysis. The whole paragraph has been adapted accordingly.
Comment 10: The last paragraph is a repetition of information presented in the discussions; I suggest removing it.
Response: We thank the reviewer for the relevant comment. We have removed the sentence has suggested.
Reviewer 2 Report
Comments and Suggestions for AuthorsOverall, the manuscript is well-structured, and the study methodology is clearly described. However, a key issue identified is the statistical analysis of the data. Based on the reported standard deviations, it appears that the data do not follow a normal distribution, which renders ANOVA an inappropriate statistical method. To ensure a more robust statistical analysis and valid conclusions, I recommend using non-parametric methods, such as the Kruskal-Wallis test. I suggest revising the statistical analysis accordingly and resubmitting the manuscript as a new submission.
Additionally, I recommend incorporating more recent references. Several systematic reviews and meta-analyses have been published in high-impact journals that would be valuable to include in the manuscript.
Author Response
Comment 1: Overall, the manuscript is well-structured, and the study methodology is clearly described. However, a key issue identified is the statistical analysis of the data. Based on the reported standard deviations, it appears that the data do not follow a normal distribution, which renders ANOVA an inappropriate statistical method. To ensure a more robust statistical analysis and valid conclusions, I recommend using non-parametric methods, such as the Kruskal-Wallis test. I suggest revising the statistical analysis accordingly and resubmitting the manuscript as a new submission.
Response: We thank the reviewer for the relevant comment. We have double checked with a biostatistician and consequently re-run the analysis. The whole text has been adapted accordingly.
Comment 2: Additionally, I recommend incorporating more recent references. Several systematic reviews and meta-analyses have been published in high-impact journals that would be valuable to include in the manuscript.
Response: We thank the reviewer for the relevant comment. We have added some relevant updated references on this topic as suggested.
Reviewer 3 Report
Comments and Suggestions for AuthorsDear Authors, soon as I got suggestion to review your manuscript I was excited to see such a unique study design! I definitily see the potential in your manuscript to catch the eye of the readers, however, there are some suggestions and improvments that need to be done in order to make your manuscript suitable for publishing in Prosthesis.
1. Line 47 – you should revise the sentence to fully define abbesrvation Patient-reported outcomes (PROs). i.e….esthetics, and patient reported outcomes such as quality of life…
2. Ethical considerations – lines 103-106, you should state which exact institution(s) gave approval to conduct this reasearch, as well as trial registration number or document number
3. After fully reading study desing, I have concerns regard it. In my opinion, this should be a case presentation, not pilot-study. Have you done sample size calculation for pilot study?
4. Lines 114-117 – please justify this statement with the literature
5. Figure 1 – I do not see the point of this figure, please explain it better and focus it. The Figure 1 should be referenced in the main text before its first apperance.
6. Line 138-139 please state exact software version, company name, city and the state of the company. Same in the line 155.
7. Line 192 – please explain in short the term CT fiducials, and then break this sentence into two
8. Figure 5 – the caption of the figure should be improved for better figure description
9. The results are clearly presented
10. Lines 311 – 324 – It is clear how you discuss the development of the research question, however, please support it with the comparison from literature.
11. Lines 359 – 361 – please support it with the literature
Author Response
Comment1: Line 47 – you should revise the sentence to fully define abbesrvation Patient-reported outcomes (PROs). i.e….esthetics, and patient reported outcomes such as quality of life…
Response: We thank the reviewer for the relevant comment. We have revised the definition as suggested.
Comment 2: Ethical considerations – lines 103-106, you should state which exact institution(s) gave approval to conduct this reasearch, as well as trial registration number or document number
Response: We thank the reviewer for the relevant comment. As clearly stated within the Manuscript, since this study did not include any clinical intervention on humans ethical approval was not required by the local legislation.
Comment 3: After fully reading study desing, I have concerns regard it. In my opinion, this should be a case presentation, not pilot-study. Have you done sample size calculation for pilot study?
Response: We thank the reviewer for the relevant comment. The present study is the first study applying this methodology in a cadaver model. Therefore, the authors did not have any previous reference to perform a proper sample size calculation. Being aware of this limitation, we have listed it as such within the discussion section.
Comment 4: Lines 114-117 – please justify this statement with the literature.
Response: We thank the reviewer for the relevant comment. We have revised the definition as suggested.
Comment 5: Figure 1 – I do not see the point of this figure, please explain it better and focus it. The Figure 1 should be referenced in the main text before its first apperance.
Response: We thank the reviewer for the relevant comment. We have replaced Figure 1 with a new image which clearly reveal the used methodology as suggested.
Comment 6: Line 138-139 please state exact software version, company name, city and the state of the company. Same in the line 155.
Response: We thank the reviewer for the relevant comment. We have added all relevant missing information as suggested.
Comment 7: Line 192 – please explain in short the term CT fiducials, and then break this sentence into two.
Response: We thank the reviewer for the relevant comment. We have added all relevant missing information as suggested.
Comment 8: Figure 5 – the caption of the figure should be improved for better figure description. Response: We thank the reviewer for the relevant comment. We have expanded the description as suggested.
Comment 9: The results are clearly presented.
Response: We thank the reviewer for the relevant comment.
Comment 10: Lines 311 – 324 – It is clear how you discuss the development of the research question, however, please support it with the comparison from literature.
Response: We thank the reviewer for the relevant comment. We have added relevant references to support this statement.
Comment 11: Lines 359 – 361 – please support it with the literature
Response: We thank the reviewer for the relevant comment. We have added relevant references to support this statement.
Round 2
Reviewer 1 Report
Comments and Suggestions for Authors
Dear authors, I appreciate your effort to answer all the questions and improve the manuscript.
Author Response
Reviewer 1
No comments required
Reviewer 2
We thank the reviewer for this valuable comment. We have added the required information as suggested by the reviewer.
Reviewer 3
No comments required
Reviewer 2 Report
Comments and Suggestions for AuthorsPlease include median values and interquartile ranges in all tables. Given the high standard deviations in these groups, median values are a more representative measure than the mean.
Author Response
Reviewer 1
No comments required
Reviewer 2
We thank the reviewer for this valuable comment. We have added the required information as suggested by the reviewer.
Reviewer 3
No comments required
Reviewer 3 Report
Comments and Suggestions for AuthorsNo further comments.
Author Response
Reviewer 1
No comments required
Reviewer 2
We thank the reviewer for this valuable comment. We have added the required information as suggested by the reviewer.
Reviewer 3
No comments required
Author Response File: 
Author Response.docx
